Medicare Enrollment Application-For Eligible Ordering And Referring Physicians And Non-Physician Practitioners {CMS-855O}

MEDICARE ENROLLMENT APPLICATION ENROLLMENT FOR ELIGIBLE ORDERING, CERTIFYING AND PRESCRIBING PHYSICIANS, AND OTHER ELIGIBLE PROFESSIONALS CMS-855O SEE PAGE 1 TO DETERMINE IF YOU ARE COMPLETING THE CORRECT APPLICATION AND FOR INFORMATION ON WHERE TO MAIL THIS COMPLETED APPLICATION. American LegalNet, Inc. www.FormsWorkFlow.com DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-1135 Expires: 01/20 WHO SHOULD COMPLETE AND SUBMIT THIS APPLICATION Most physicians and eligible professionals (as defined in section 1848(K)(3)(B) of the Social Security Act) enroll in the Medicare program to be reimbursed for the covered services they furnish to Medicare beneficiaries. However, with the implementation of Section 6405 of the Affordable Care Act, CMS requires certain physicians and eligible professionals to enroll in the Medicare program for the sole purpose of ordering or certifying items or services for Medicare beneficiaries, and prescribing Part D drugs. These physicians and eligible professionals do not and will not send claims to a Medicare Administrative Contractor (MAC) for the services they furnish. The physicians and eligible professionals who may enroll in Medicare solely for the purpose of ordering and certifying and prescribing Part D drugs include, but are not limited to, those who are: · · · · · · · · · Employed by the Department of Veterans Affairs (DVA) Employed by the Public Health Service (PHS) Employed by the Department of Defense (DOD)/Tricare Employed by the Indian Health Service (IHS) or a Tribal Organization Employed by Federally Qualified Health Centers (FQHC), Rural Health Clinics (RHC) or Critical Access Hospitals (CAH) Licensed Residents (as defined in 42 C.F.R. section 413.75(b)) in an approved medical residency program Dentists, including oral surgeons Pediatricians Retired physicians who are licensed Once enrolled, you will be listed on a CMS database and will be deemed eligible to order and certify services and items or prescribe Part D drugs for Medicare beneficiaries. Physicians and eligible professionals can apply to enroll for the sole purpose of ordering and certifying items and/or services to beneficiaries, and prescribing Part D drugs in the Medicare program or make a change in their enrollment information using either: · The CMS-855O application available on the Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or · The paper CMS-855O application. Be sure you are using the most current version. For additional information regarding the Medicare ordering and certifying and Part D prescribing enrollment process, including Internet-based PECOS and to get a copy of the most current CMS-855O application, go to https://www.cms.gov/MedicareProviderSupEnroll. The information you provide on this form will not be shared. It is protected under 5 U.S.C. Section 552(b)(4) and/or (b)(6), respectively. See the last page of this application to read the Privacy Act Statement. NATIONAL PROVIDER IDENTIFIER INFORMATION The National Provider Identifier (NPI) is the standard unique health identifier for health care providers and suppliers and is assigned by the National Plan and Provider Enumeration System (NPPES). You must obtain an NPI prior to enrolling in Medicare. Applying for the NPI is a process separate from Medicare enrollment. To obtain an NPI, you may apply online at https://NPPES.cms.hhs.gov/NPPES/Welcome.do. For more information about NPI enumeration, visit http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/ MedicareProviderSupEnroll/index.html. CMS-855O (01/17) American LegalNet, Inc. www.FormsWorkFlow.com 1 INSTRUCTIONS FOR COMPLETING THIS APPLICATION All information on this form is required with the exception of those fields specifically marked as "optional." Any field marked as optional is not required to be completed nor does it need to be updated or reported as a "change of information" as required in 42 C.F.R section 424.516. However, it is highly recommended that once reported, these fields be kept up-to-date. · Type or print all information so that it is legible. Do not use pencil. Blue ink is preferred. · Complete all applicable sections and furnish your NPI. · Keep a copy of your completed Medicare enrollment application for your records. · Sign and date Section 8 of this application using blue ink. ACRONYMS COMMONLY USED IN THIS APPLICATION MAC: Medicare Administrative Contractor NPI: National Provider Identifier PECOS: Provider Enrollment Chain and Ownership System WHERE TO MAIL YOUR APPLICATION The MAC that services your state is responsible for processing your enrollment application. To locate the mailing address for your designated MAC, go to https://www.cms.gov/MedicareProviderSupEnroll. CMS-855O (01/17) American LegalNet, Inc. www.FormsWorkFlow.com 2 SECTION 1: BASIC INFORMATION A. REASON FOR SUBMITTING THIS APPLICATION Check one box and complete the sections of this application as indicated. You are enrolling for the sole purpose of ordering/certifying and/or prescribing Part D drugs You are currently enrolled solely to order and certify and/or prescribe Part D drugs, and are updating your information You are voluntarily withdrawing your Medicare enrollment to solely order and certify and/or prescribe Part D drugs Complete all sections Complete Section 2A, all other applicable sections and Section 8 Complete Section 2A (Name, SSN and NPI) and Section 8 B. REASON YOU ARE ENROLLING SOLELY TO ORDER AND CERTIFY OR PRESCRIBE PART D DRUGS Instructions: Choose only one reason from Group One OR one reason from Group Two You are enrolling in Medicare solely to order and certify or prescribe Part D drugs because you are: Group 1 Employed by the DVA Employed by the PHS Employed by the DOD/Tricare Employed by the IHS or a Tribal Organization Employed by a Medicare-enrolled FQHC Employed by a Medicare-enrolled RHC Employed by a Medicare-enrolled CAH Group 2 Physician not employed by any entity in Group 1 Eligible Professional not employed by any entity in Group 1 Licensed Resident not employed by any entity in Group 1 Dentist not employed by any entity in Group 1 Pediatrician not employed by any entity in Group 1 Retired physicians who are licensed Other (specify): SECTION 2: IDENTIFYING INFORMATION A. PERSONAL INFORMATION First Name Other Name, First Your name, date of birth, and social security number must match your social security record. 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